Diagnostic dilemma: Altered sensorium while taking hot water bath Minimising disability in stroke survivors

Sir, It was interesting to read article “Unexplained neurological events during bathing in young people: Possible association with the use of gas geysers”.[1] We had a somewhat similar experience. From November 2005 to January 2008 we have come across 24 patients (age 12 – 45 years) who became confused or comatose while taking hot water bath in winter season. None of them had past history of seizure disorder. The gas geysers were fi tt ed in poorly ventilated bathrooms. In every case family member had to break open the door of bathroom to rescue the patient. Eight patients were comatose when brought to the hospital. Of remaining 16 patients, 10 were in delirious state while six had regained normal sensorium by the time they reached to the hospital. Four patients could vaguely recall feeling of suffocation, dizziness and generalized weakness before loosing consciousness. But none reported any foul smells, or other premonitory symptoms. Their vital parameters were normal except tachycardia up to 120/m and tachypnea up to 30/m was noted. Oxygen saturation was 95-100%. Color of skin was normal in all the cases. There was no odor in their breath. No tongue bite or other injury marks seen. In eight patients, pupils were semi dilated and sluggishly reacting. Fundus examination was normal. There were neither lateralizing signs nor any sign of meningeal irritation present. Dystonic posturing was seen in 5 cases. Hemogram, metabolic profi le, MRIHead and EEG were normal in all the cases. Arterial blood gas (ABG) analysis was done in 18 patients and was found to be normal. All patients were treated with oxygen inhalation. Total duration of unconsciousness or confusion aft er detection varied from 1 hour to 7-8 hours. All patients made complete recovery.

Sir, It was interesting to read article "Unexplained neurological events during bathing in young people: Possible association with the use of gas geysers". [1] We had a somewhat similar experience. From November 2005 to January 2008 we have come across 24 patients (age 12 -45 years) who became confused or comatose while taking hot water bath in winter season. None of them had past history of seizure disorder. The gas geysers were fi tt ed in poorly ventilated bathrooms. In every case family member had to break open the door of bathroom to rescue the patient. Eight patients were comatose when brought to the hospital. Of remaining 16 patients, 10 were in delirious state while six had regained normal sensorium by the time they reached to the hospital. Four patients could vaguely recall feeling of suffocation, dizziness and generalized weakness before loosing consciousness. But none reported any foul smells, or other premonitory symptoms. Their vital parameters were normal except tachycardia up to 120/m and tachypnea up to 30/m was noted. Oxygen saturation was 95-100%. Color of skin was normal in all the cases. There was no odor in their breath. No tongue bite or other injury marks seen. In eight patients, pupils were semi dilated and sluggishly reacting. Fundus examination was normal. There were neither lateralizing signs nor any sign of meningeal irritation present. Dystonic posturing was seen in 5 cases. Hemogram, metabolic profi le, MRI-Head and EEG were normal in all the cases. Arterial blood gas (ABG) analysis was done in 18 patients and was found to be normal. All patients were treated with oxygen inhalation. Total duration of unconsciousness or confusion aft er detection varied from 1 hour to 7-8 hours. All patients made complete recovery.
Besides confusion and convulsions, severe neurological manifestations may occur aft er days or even weeks aft er an acute poisoning or aft er long term repeated exposure. Common problems encountered are diffi culty with memory, dementia, Parkinson-like syndromes and cortical blindness. [2] Binding of carbon monoxide (CO) to Hb causes retention of oxygen that would otherwise be delivered to the tissue. Blood oxygen content is actually increased but none is given to the tissues. [3] Because pulse oximeter testing and ABG analysis does not refl ect tissue hypoxia, these tests are of litt le use to screen or diagnose CO poisoning. [4] Levels of carbon monoxide bound in the blood can be determined by measuring carboxyhemoglobin. Serious toxicity is oft en associated with levels above 25%. [5] Hyperbaric oxygen is also used in the treatment of CO poisoning, which increases carboxyhemoglobin dissociation to a greater extent than normal oxygen. [6] If no other alternative is available, install geyser outside and give only the hot water outlet pipe in the bathroom. Otherwise one should ensure cross ventilation in the bathroom and install CO detectors. CO can easily be detected by the filtering paper impregnated by the solution of palladium chloride which turns black on exposure to CO.

Minimising disability in stroke survivors
Sir, The Editorial on "Litt le strokes, big trouble and more" is thought provoking. [1] Stroke prevention by risk factor intervention would be a practical way but we do not have population based national data to plan prevention strategies. To estimate the magnitude of problem, we urgently need population based regional surveys using standard terminologies and methodologies. [2] On the other hand, Quality of Life in stroke survivors is an immediate problem. For example, in Mumbai Stroke Registry [3] among other factors (e.g. age, stroke subtype and associated risk factors), the neurological deficit (by NIHSS score) at onset correlated with outcome status (by Barthel Index or Modifi ed Rankin Scale) at 28 days. Mild defi cit at onset was associated with good recovery whereas; moderate to severe neurological defi cit had poor outcome. Therefore, the aim of immediate treatment will be to restrict the extent of brain damage and minimize post-stroke disability.
Unfortunately, lack of public awareness on warning symptoms, transportation diffi culties and paucity of acute care beds are major handicaps. With limited number of neurologists in our country, one will have to depend on expertise of local medical practitioners to initiate emergency intensive management (not tPA) until patient is shift ed to acute care unit. Thus, training of local physicians in acute stroke care is most urgently needed. In other words, our emphasis on sophisticated advanced technologies requires rethinking and our concern for improving quality of life in stroke survivors needs greater emphasis.

Author's reply
Sir, I am delighted to note that Prof. Dalal [1] has brought out the importance of early intervention to reduce potential disability in stroke survivors. Stroke is a major cause of mortality and morbidity in developing countries as well as more advanced countries. Several studies have confi rmed that neurological defi cit at onset is a predictor of late sequlae and resultant disability in stroke survivors. The fi rst three to six hours aft er the onset of stroke is the critical period in which early intervention is most likely to reduce morbidity and fi nal disability. The initial neurological defi cit is an indicator of the size of the brain infarction in most situations. Yet, there can be progression of the stroke or added defi cits because of increasing cerebral edema. The role of a primary physician to diagnose and institute early treatment for stroke is oft en underestimated and an effi cient stroke center and stroke team is recommended. In India and other countries with resource crunches, it is important that the primary care physicians are appropriately trained to diagnose and institute early treatment for stroke. General care regarding respiration, cardiac care, fluid and metabolic status, control of blood glucose and blood pressure, and prevention of systemic complications are very important. A good review of optimal management of physiological variables during acute stroke was recently published in this journal. [2] Att ention to these aspects can be done in any institution with limited facilities yet it forms the fi rst line brain protectant treatment that may reduce the morbidity.

Sanjeev V. Thomas
Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum -695 011 India. E-mail: editor@annalsofian.org